Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Wednesday, March 30, 2011

The Teen, The Bride, and I just returned from four days in Canada. You may have heard of Canada. It’s the big country to the north that plays hockey and stubbornly refuses to become a state. Before this trip, what my son knew about Canada came from my copy of Jon Stewart’s “America: The Book,” where a demure Samantha Bee periodically interjects in the discussion of our political life to ask “Would You Like the Hear How We Do It In Canada?” The Bride, who went to college at 14 and so never studied things like high school geography, knew Canada was not anywhere near Belgium. She also never took high school biology, but she has learned where babies come from, which is probably why we’re not having any.

This was my third trip to the frozen north. The first was almost twenty years ago for a medical meeting, which really involved no tourism. The second was supposed to be a week-long excursion with someone I was dating at the time, a girl who actually spoke Cajun French so we wouldn’t be totally lost in Montreal. She backed out at the last minute but I went anyway, and spent most of my time in Ontario mourning my romantic misfortune. However, on the train from Ottawa to Quebec I met a most charming and beautiful woman from Trois Pistoles by the delightfully melodic name of Natalie Chantal Lavoie, who spoke such wonderfully accented English that the fact that I could barely understand her seemed superfluous at the time (To be honest, it seems kind of superfluous even today. She’s number two on the “Where are you now?” list. And don’t pretend you don’t have a list, because everyone does.)

So essentially I still have the same understanding of Canada as most Americans, which is the following:

Hockey.

Canadians are more witty then we are but without the inherent bawdiness and occasional cross-dressing on the English. They listen to pop groups like “5 Neat Guys.” All televisions shows start with the traditional “Coo-roo-coo-coo-coo-coo-coo! “Coo-roo-coo-coo-coo-coo-coo! (I watched SCTV.) They shoot rubber chickens at things for fun. People from Canmore are silly. (I watched the Royal Canadian Air Farce.)

Canadians are handy. They can wear overalls and flannel shirts without being thought of as lesbians. Even the men. ( I watched Red Green.)

Canadians speak English and French. This means they understand all the words to “Lady Marmalade.”

Hockey.

The Royal Canadian Air Force Snowbirds fly smaller planes than the Blue Angles, but more of them. That’s very cool.

The dollar coin is called a looney, which is funny.

Gordon Lightfoot is from Canada. Bob Dylan is from near Canada. Both sing as if suffering from severe intestinal distress. Coincidence? I think not.

Canadians can probably look over Sarah Palin’s house all the way to Russia.

Hockey.

Draft dodgers used to go to Canada. I can’t judge if that choice was right or wrong. But when you match up swamps, bullets, and the Viet Cong against bacon, beer, and Tim Horton’s donuts, it’s pretty clear why some folks jumped the border. (Speaking of which, wouldn’t the perfect Canadian food be a Tim Horton donut with apple filling and bacon sprinkles? I’m just sayin’.)

Canadians are multicultural, highly taxed, have cheap drugs, and unfailingly polite. They have universal health care that is either a glorious ideal of care and compassion or a satanic assault on our individual freedoms, depending on whether I’m watching MSNBC or Fox News.

The Queen is still officially in charge of Canada, and if she really wanted to she could just dissolve their whole government lock, s tock, and barrel and replace it with the an amalgamation of the Hudson’s Bay Company and some disgruntled pilgrims, installing a scandalous relative who needs to be out of the UK as Governor-General.

Hockey.

*********One of the most interesting things about Canada…or at least about Whistler, British Columbia, the small resort town north of Vancouver that was our final destination…is that a lot of Canadians aren’t. The place was rife with young workers from New Zealand, Australia, England, and South Africa, with a fair number of Japanese and Chinese thrown into the mix. In talking to them, I got the impression that it was considered routine for them to spend a good part of their twenties living abroad, working small service jobs to make ends meet while seeing the world and having one heck of a good time. This seemed almost anathema to the American experience, where we tend to get plugged into career tracts just after college and a semester abroad is considered enough international exposure for any one person. It reinforced to me why Americans are often seem small-minded and xenophobic, because we voluntarily and willfully restrict our exposure to the rest of the world. And while plenty of Americans travel abroad, travel itself teaches very little. Life is the real professor.

********For my souvenir, The Bride purchased a pair of red and white boxer shorts emblazoned with the Maple Leaf of State. I presume this is so one day when I am in the nursing home, the aide can prepare to change me and suddenly exclaim, “OH CANADA!” (Which has got to be the oldest line in the Great Joke Book of the North.)

********I have decided that I want to live in a town called Squamish. It’s about 40 km from Vancouver and another hour down the road from Whistler. It’s a beautiful area, with mountains on one side and oceans nearby. The indigenous people of the region have a strong heritage, and from what I understand Squamish is particularly popular in summer with rock climbers. (This sounds like job security for an emergency physician.) Squamish has those things you really need: A Wal-Mart, a London Drug, a Canadian Tire, and a Tim Horton’s Donut Shop. But I think I’m most intrigued by trying to figure out if, after the Great Migration, I would be known as a Squamite. Or Squatter. Or Squamanian. Or Squamapolitan. I could have fun for the rest of my days with this problem alone.

********I was a little hesitant about taking The Teen skiing. This trip was something I had always wanted to do as the ultimate family outing, but still I knew that at age 13, I would be trying to cultivate enthusiasm against the potent opposition of the Sullen Years. He ended up having a really good time but, true to expectations, immediately after telling me that a run was “AWESOME!” he returned to form when I asked him if now he liked skiing. “It’s okay, I guess,” he replied, catching himself before enthusiasm got in the way of his image.

He did really well for his first time out. His skiing ability is best thought of as a controlled standing fall, with the skis in a snowplow vee all the way down. Turning, when it happens, is a slow and deliberate process, so speed control on the steeper slopes can be something of a problem. But point him the right way on most of the easier green slopes and he takes off like a small helmeted rocket.

The weekend was chock-full of those proud father moments that you can’t describe in words, though every father knows what I mean…when he went down the first beginner slope all by himself, when he told me he was skiing on ahead because he didn’t need me alongside to back him up. But there was a big ol’ honker of a father terror moment as well.

We had hit a steep patch on a slope that was difficult for Brendan, and he fell in a ball of powder and ice. Fortunately, he had already perfected the “crucifixion” fall, which is where you lay on the snow with your legs together, throw your arms out to the sides, and yell loud enough to remind everyone how you’ve been forsaken.

To get him back up, he needed to take off his skis; and as I was ten yards ahead of him I needed to take mine off as well to get up the slope and help him back to his feet. He stood up, and I held him steady by the boots as I lay on the snow and told him to meet me at the bottom of the hill, about 100 yards down in plain sight. This plan would have worked out fine, except that it took me a while to get my own skis back on. When I did, I looked to the bottom of the Hill and he was GONE.

Dread took hold of my heart. I was pretty sure nothing major had happened…he’s a pretty loud kid when he needs to be, and if he had gone off the trail I was certain I would have heard something. So while I had some trepidation in my heart, I was doing okay until the two guys from the ski patrol came whizzing by.

Now I’m officially terrified. My kid has gone off a cliff or broken something that is best left intact. There’s no doubt in my mind that something awful has happened. So I finally get my skis back on and get down the hill as fast as I can. I still don’t see him. Panic rises. I speed up and he’s still not there. I kept going, now in my old creaky guy version of a racing crouch to go even faster. But as my knees screamed at me to stop, I started to notice that even though the slope was getting steeper, he wasn’t down there in the snow. For that matter, neither was the ski patrol anywhere to be found. The only thing I could hear was the wind as I sailed down the hill, and not the shrill cries of a child in pain. So I started to relax, and as I took a deep breath and sighed I saw in the distance a small figure in a gray plaid jacket and red ski boots, snowplowing his way gamely down the hill, cautious but confident, eminently on his own. Another proud father moment revealed.

Next year we work on turns.

********Because The Teen is…w ell, a teen…bodily noises and products are never far from his mind. So when we went into the local rock and gem shop to hunt down a souvenir, he was naturally delighted to discover that one could purchase a coprolite. (For those who lead normal lives, a coprolite is fossilized dung.)

Some time later, we’re in a hotel restroom. He’s taking an awfully long time. I try to take it in stride. After all, he is an adolescent boy. Is he on a journey of self-discovery, looking at his body and marveling at the changes that occur as he goes from boy to man?

A few more minutes pass by, and I’m just a bit concerned. So I ask through the door, “Hey, what’s going on in there?’’’

He answers. “I’m making the coprolite of the future.”

(This line of conversation was followed the next day while having dinner in Seattle at a Chinese place that overlooks a row of houseboats. We were talking about what it would like to be to live on a houseboat, and especially what we would do with our dogs. Do you have to walk them all the time, or do they just kind of learn to put “parts” out over the edge as needed? The Teen had the ready answer. “Just send them to the poop deck.”)

********Overall, we had a great time. The Teen learned to ski, The Bride got to jump off things (it’s called “Zip-Lining”), and I felt like a genuine Head of Household befitting my tax status. And as we came back to the US on the Amtrak Cascades (business class is brilliant fun) one memory that will stay with me is the stark contrast between the old but well-maintained Central Station in Vancouver and the decrepit King Street Station in Seattle. You could actually start to see the difference in route. Just like in America, Canada has older infrastructure. And the United States certainly has no monopoly on rusty trackside containers parked outside of warehouses or fenced-off vacant lots. But somehow things just seemed more orderly, more organized, the mess somehow arranged with care. And when we got off at the station, to go from four days of people going out of their way to be nice to having to persuade the baggage handlers to actually give you your bags that you can see on the cart before slamming the steel door on your hand, and being harassed in broken English (broken American?) by taxi drivers from nations you’re pretty sure would be perfectly happy to eliminate you and your co-religionists from the earth, it was even more clear what Canada got right.

I’m sure that there are a host of sociologists who can wax eloquently about the sociocultural factors that have made Canada different than the US. Whatever it is, it seems to this admittedly superficial observer that while America may still offer more economic opportunity than anywhere in the world, Canada excels at the business of life. Which is why, at some point in the future, I might really need to ask if BC will have me. I think I’d make an excellent Squamite.

Monday, March 28, 2011

It’s seven AM and the morning crew is coming in. Jason Fawver (he of Gravity Storm fame) is trying to decide where to go for breakfast. After ample discussion and soul-searching, he opts for the “One-Legged Restaurant.” It turns out this is IHOP. And what’s the waitress’s name? Eileen, of course. And be sure to tip her.

********I’ve got a deaf patient with a leg injury, and I’m trying to get her to wiggle her toes so I can make sure all the nerves to the foot work okay. She can’t read lips and I can’t sign, so it’s becoming a more difficulty proposition by the moment. Finally I get the idea to take off my shoe and place my stockinged foot next to hers, demonstrating for her the desired action. The nurse working with me deadpans, “Good thing you’re not doing a pelvic exam.”

********The young adult make says he’s had rectal pain for the past three weeks. “And,” he notes,“ I’m getting pretty tired of this crap.”

********The ambulance is called out for an elderly man with Alzheimer's Disease complaining of chest pain. The overworked but nonetheless insightful nurse says, "Give him five minutes. He'll forget all about it."

********A man from the state mental hospital comes in becuase he's been...umm...inserting things into places they don't belong. Notably, a deodorant stick has made it's way up his back passage. Says the nurse, "I guess that mean his s..t doesn't stink."

Thursday, March 24, 2011

As much as I would like to firmly believe in the afterlife, I have to confess to some moments of existential doubt. This is not something I feel particularly guilty about…if nothing else, I figure I’m in pretty good company with virtually all theologians of note. And like them I’m usually able, albeit in a crude fashion, to reason myself out of these insecurities. That being said, I’ve always thought there was also something to be said for the Anglo-Saxon heroic ideal personified by Beowulf, that one lives on through fame, the deeds performed and the treasures won.

The limits of fame are that while deeds are easy to record, thoughts are not. It’s fairly easy to mythologize anyone based on their record. It’s much harder to know what they actually thought. So when someone asked me why I try to keep up with a blog (with admittedly varying degrees of success), I think that maybe the need to document my thoughts as well as my deeds is part of it. It’s part and parcel of my own shot at fame, even if fame for me is nothing more than my descendants reading this stuff and wondering why they ever let Great-Grandpa out of the asylum.

Along with the blogging, my hope is to write a few books before Grendel takes me down. One is collection of essays about life in the ER, focusing on what really happens, the daily grind, rather than just the glory and the pathos. A second explains how a public health approach is the best way to address health and health care in America. The third is the Great American Novel (or at least The Great Novel Within The Local Zip Code) about a guy who thinks he has special powers but is actually handicapped by living exclusively in the moment on “dog time.” The latter is very much still in the conceptual phase, and I fear I’ll only fully understand my idea after I’ve put myself on copious doses of antipsychotics for a few months and then go through an abrupt withdrawl. This means that I’ll have to wait to write it until I’m done practicing medicine, and given that The Teen has now decided he wants to be a veterinarian this project is clearly fifteen years and multiple tuitions away. (The Bride has read this and wishes it to be noted that she paid for her own damn graduate school, thank you very much.)

The process of writing the blog, let alone a book, has given me a much greater appreciation for those who write. Writing is genuinely hard work, and my personal schedule of working twelve hour ED shifts at all times of the day or night certainly doesn’t help. (I’ve noticed that since I switched to doing twelve hour shifts instead of eights my output has decreased dramatically, as most days you’re simply too tired or have too many tasks of “normal living” to do.) It’s no wonder that many authors are either professional journalists or copywriters who know how to write and to write fast, or academicians who are essentially paid to take empty time and fill it with authorship. Having tried even just this blog, I have a much greater admiration for people like former high school English teacher Stephen King who wrote his first book on a TV tray between dinner and bedtime. I also think that as a writer, I suffer from a normal upbringing. Being raised in a nuclear, upper middle class, reasonably functional family in the Midwest is unfortunately not great fodder for thinly disguised fiction nor inspirational look-at-all-I’ve-overcome memoirs. I’ve pleaded with Mom and Dad on this one, but they refuse to change their non-alcoholic, non-abusive, monogamous ways. They’re not much help at all.

Despite these handicaps, there are still untold numbers of reasonably normal people like me who want to have their lives on paper. Even within the ED crowd, I know a nurse who’s working on a book, and one of my former physician colleagues is compiling tales of patients with rectal foreign bodies he has seen entitled “In Through The Out Door.” It’s probably a good thing for him. Like most of us, he undoubtedly could use a creative outlet. And his personality most assuredly resonates with the topic.

Tuesday, March 15, 2011

We’ve recently changed our terminology in the ED. Medical terminology is it’s own topic (and has been previously on this blog), but I don’t think I’ve really touched on the acronym. Acronyms are those abbreviations we use to simplify communication, and are certainly not unique to medicine ( LMFAO). But we do have our own special ones for ED use. There’s TMCTC (Too Many Complaints to Count), VND (Veak und Dizzy…accent intentional), OTDHTB (Out The Door, Hit The Bricks), III (Insurance-Induced Injury), and AMFYOYO (Adios My Friend, You’re on Your Own.)

But one of our most beloved and useful acronyms has fallen on the junk heap of political correctness. SOB (Shortness of Breath) has been replaced by SOA (Shortness of Air). Apparently some folks objected to seeing the term “SOB” featured prominently on the front of their charts. In truth, I’m not sure how you can be short of air. There’s a lot of it around, and as far as we know it’s not running out any time soon. You can actually run out of breaths, so SOB seems to be more clinically accurate.

With SOB in mind, it is true that the terms we in the healing professions use to describe a small minority of suboptimal patients are not always as polite as they might be. In the ED, we try to be as culturally sophisticated as we can while still conveying the essential message, preferring to use terms such as “oxygen thief” (one who steals perfectly good oxygen from the atmosphere at the cost of CO2 production and global warming). And as far as SOB goes, well, sometimes the patients just are.

Strangely enough, it’s not our habit to note when someone is a decent citizen, simply because most people are. I don’t know why that is. Perhaps it’s for the same reason that Man Bites Dog is a headline while Dog Bites Man is not. So we tend to reserve the terms “good” and “nice” only for people for people who are genuinely sick or in a bad situation. For example, the patient with end stage lung cancer whose wife has been trying to take care of him at home and brings him to the hospital because she literally can no longer care for him are “nice people.” They’ve done all they could and then some, and failed. And they qualify as nice because of the immutable ED law that Nice People Get Bad Disease and Dirtbags Live Forever.

The one exception seems to be our frequent use of the word “pleasant,” often as part of the phrase “pleasantly demented.” Of course, not all patients with dementia act particularly pleased about it. Many are angry or agitated, but for whatever reason I can’t ever recall saying that someone was “really teed-off demented.” I wonder if this is because I have this belief…unsupported by fact, of course, but it seems to work…that when your higher mental functions and processes are stripped away, you really present as the person you always were. And because dementia is a rotten thing to have, we try to somehow make it more palatable by rewarding a cheerful demeanor. It’s another manifestation of the immutable Law of the ED. If you’re pleasant now, you were probably pleasant before; and dementia is a bad disease. Consistency matters.

Wednesday, March 9, 2011

The lonely man with the bad heart and social isolation (see “Cat Nips," February 5th) has returned three times in the last six days. I saw him on his third visit, when he developed chest pain after receiving an injection of a blood thinner. His workup was negative, but given his history he was admitted to have his blood tests and EKG checked once more the following day before declaring him free of acute heart damage and sending him out to return again, probably after he has another shot the following day. For, as one of the nurses pointed out, “He’ll have chest pain with the shot. He’ll have chest pain without the shot. He’ll have chest pain if you get the shot.” And while I’m trying to suppress a snicker while I’m doing the paperwork…because I do feel kind of badly for him, given that he says he likes it when I take the time to talk to him in the ED and the fact that he’s going to die sooner rather than later…I’m presented with a prescription to sign. It has his name on it, and it reads, “Cats. #8. Feed as directed.”

Tuesday, March 8, 2011

While the Doctor’s Lounge here at work has a virtually unending supply of Pepsi products, every now and then I prefer a real honest-to-goodness Coke. Fortunately, the c cafeteria features a genuine Coke machine to satisfy these periodic cravings, and it was pushing midnight when I headed down the terraced steps leading to the vending machines.

Hospital vending machines usually offer more fare than the usual soda, candy, and chips. That’s because health care is twenty-four hour industry, but food services are not. So there are machines that feature more substantive foods such as burgers, sandwiches, and salads. In this particular cafeteria, these kinds of treats are in a machine that has tiers of rotating circular trays. The trays bring the food to the front where they can be pulled out through small plastic windows.

I’m sure that someone checks what’s in the machine and doesn’t leave anything in there for an inordinate amount of time. However, because the food is often under continual lighting in the cafeteria and has been frozen, thawed, and frozen on any number of occasions, the color and consistency is often just not right. Because these morsels are sometimes questionable, the machine is known popularly as The Wheel of Death. And acquisition of a meal from The Wheel has become its own kind of triage tool in the ED. For example, two nights ago I saw a young woman complaining of severe abdominal pain while munching on a vended hamburger of uncertain character. It was a given that if she could stomach that, there could be nothing serious going on.

(As an aside, the ability to eat just about anything in the ED…but especially Fritos, Doritos, french fries, or chicken nuggets…while complaining of nausea, vomiting, or abdominal pain will automatically downgrade your ‘emergency” problem to…well, whatever we decide it is. The same goes for your severe level of pain or discomfort if I walk into the room and need to wait five minutes for you to get off the cellphone.)

The walk to the café is actually one of the most pleasant journeys you can take within our institutional walls. The hospital has built an indoor atrium with a rock garden full of real water, plants, and dirt complete with pre-recorded songbirds. The steps that lead form the main floor to the cafeteria descend through this arboretum. It’s a place where I always pause for just a moment to smell the freshness of the greenery within the bosom of antisepsis, or feel the warmth of the sun at the height of the day. It is not the kind of place you expect find a giant stuffed colon. Which is exactly what happened.

It turns out that the display was part of National Colon Health Month. It needs to be noted that I am in favor of treating your colon right. I recognize the need for balanced diets including the liberal intake and fluids, fruit, and fiber. I know that screening for colon cancer, including testing of stools for occult blood and colonoscopy, is one of the most cost-effective tools we have for the successful treatment of bowel cancer. I am also the guy who believes so strongly in colon awareness that at the Kansas Department of Health and Environment employee picnic, I dressed up in a polyp costume. (In retrospect, I may have actually taken the role too far. Convinced that my costume needed a personality, I decided to be an angry polyp and walked among the staff, pointing at plates of burgers and chips and yelling “MORE FIBER!” Yes, there are pictures somewhere. No, you cannot see them.) All this being said, I had never really considered the possibility of what do to when confronted with a giant twelve-foot-long stuffed fabric colon cascading through the atrium suspended from two metal uprights.

So I did the only thing I could. I became inspired by the display, and decided to dedicate my life to being an advocate for colon health. Everywhere I go I’ll carry small cards and a bottle of chemicals to test the stools of random passers-by for blood. I’ll stand on street corners and espouse the cause. I may even take the giant stuffed colon and wrap it around my shoulders to wear as a boa, bringing my message to the swankiest nightspots, or perhaps I’ll use it as a rope to tie myself to the White House gates and demand…well, I’m not sure yet, but it’ll come to me.

The above paragraph is, of course, a lie. The only thing I could really think of to do was get my picture taken with it. And so now in my cellphone there is a picture of me standing under the colon; one where I’m standing on top of the rocks in the atrium with my head seen above the colon, and a third with me pointing at the colon in a most solemn and Galenic manner. Fortunately, one of my nursing colleagues felt the same sense of wonder as I, so I also have a picture of the two of high-fiving under the colon, smiling with thumbs up under the colon, and a high-fashion photo of each of us posing, looking indifferently off into the distance, hands on our hips, our respective profiles set off against a background of fabric-filled ascending bowel.

Friday, March 4, 2011

I had always assumed that the grocery business was relatively safe. And even if there were some jobs within the supermarket that might be more prone to injury than others, I never would have put the dairy staff in this category. (We are intentionally ignoring the perennial concern about fingertips in the deli slicer, and in doing so get to avoid making a strained analogy between sandwiches of tongue and hoagies of digits. Although I will note that two decades ago I sewed back on the pad of a finger lost at Gates and Sons BBQ in KC, and for the next twelve months gratitude upgraded my Beef on Bread to a Beef and a Half.)

Last night I sewed up the thumb of a young woman who had been injured by eggs. Well, maybe not the eggs themselves, but by the knife she was using to cut open a box of eggs. The funny thing is that this wasn’t her first ovolaceration. Two weeks ago she had cut her face when the knife hit a snag in the box and flew up against her cheek. Which made filling out her workplace accident report quite fun in trying to resist the urge to put under the heading of work restrictions, “May Open Egg Beaters Only.” Which is an urge I may, or may not have, given in to. Only Worker's Comp knows for sure.

*************

Two ambulances are called to a domestic disturbance. During the spat, one of the protagonists had a seizure. Watching the seizure, a second combatant had an anxiety attack.

The first patient came to ER and promptly demonstrated her seizure. She tensed up her whole body, holding her limbs rigid and trembling while producing a constant, undulating moan. She did, however, follow me around the bed with her eyes when I entered the room. You can’t do that with a seizure. So I told her it was okay to stop, and she did so immediately, letting out a large sigh as she slumped back into the bed.

The second patient was unresponsive. She was so unresponsive that when the nurse began to do a sternal rub, she immediately opened her eyes and said, “Stop doing that!” In conversation, both the patient and her boyfriend recalled that while she had been unconscious at home, she had full recall of the paramedics talking to her and rubbing on her chest. “It hurt!’ she noted. You can’t do that if you’re unconscious. (For the record, a sternal rub is not as nice as it sounds. There’s no rhythmic caress with Vapo-Rub and a nice warm, fuzzy feeling. It’s driving your knuckles into the heart of the breastbone, a painful maneuver sure to provoke some kind of response. And if there’s truly no response, there’s a real problem.)

What happened at home is that the first patient, a middle-aged female homeowner, got into an argument with the second patient’s boyfriend. The second patient’s boyfriend is also the first patient‘s daughter’s not-yet-divorced husband. The son-in-law and his girlfriend are currently living rent free in his mother-in-law's home. She's upset because they don’t pay rent and eat all her food, and the fight was a result of her attempt to evict them while they were all sitting together watching a movie. Police were called when soda cans and laptop computers began to fly through the air.

The nurse and I agreed this was a Jerry Springer moment, and we’ve decided that a good side business would be to start an ED based Jerry Springer Talent Search. For a finder’s fee, we’ll drop the names of potential guests to the Springer production staff. Could pay off a few credit cards faster than spit, for in our line of work there’s a virtually inexhaustible supply of material.

Honestly, you can’t make this stuff up.

**************

One of the tricks of working at night is getting medication for patients when there’s no 24 hour pharmacy in town. You can write a prescription, but after 9 PM (6 on the weekends) there’s no way for the patient to get it filled until the following day. The hospital inpatient pharmacy does not want to be (and in fairness, probably should not be) in the business of filling outpatient prescriptions. So there’s this stopgap scheme where we can put a sticker on a sandwich baggie and dispense enough medication to get the patient through until the next morning when the pharmacies reopen.

Occasionally, this requires a bit of math as you try to determine if you need to give the patient one or two doses of medicine to help them through the night. Last evening, it was also a reminder that working in a small town ER has its benefits. So when I was trying to figure out if I needed to give a patient a second dose of narcotic pain medication, I was told not to worry about it. The nurses knew he'd just get another dose from his mother.

****************

There was a call from an outlying ED about a patient who had swallowed a prickle. These are the little burrs that stick to your shoes and socks when you walk through an ungroomed field or a path through the woods. Anyway, she had apparently tried to pluck one off a mitten by nipping it with her teeth, and then swallowed it by accident.

There’s something about the atmosphere in the ER that resolves certain medical problems. Mostly this happens with children, whose fever of 134 degrees, gasping for breath, and inability to drink without barfing immediately disappears once they get within The Healing Walls of Health. (More than likely, it’s because the Tylenol has kicked in, popsicles are tastier than Pedialyte, and the cool night air has eased the cough. But there’s still enough voodoo in medicine that I’m willing to attribute some magic to the ethers.) Which is why, after a two hour drive in the dead of night, the patient arrived, coughed twice in the lobby, and promptly hacked up a slimy, mucus-encrusted plant burr. Treatment consistend of placing it in a specimen container, affixing a label inscribed “Mr. Prickly,” and taken home for display.

****************

An example of how the health care system works…or doesn’t…and of the Law of Unintended Consequences:

A patient came in early in the day with seizures. To get the seizures to stop, she required the use of multiple medications. Her seizures were not new…they had been fully evaluated, and she had been under the care of a neurologist, and she was already on medications. And it was known that when she had a seizure, she had a prolonged “post-ictal” state. (This is the presence of an altered level of consciousness that follows a seizure, a phase of lethargy and slowness of thought that clears over time.) Most people are back up to speed in 1-2 hours after a seizure; in her case, it had been noted that it often took twelve hours or more.

For the patient’s comfort and to keep the ED bed open, it made sense for the patient to be admitted to the main hospital to watch for resolution of her lethargy and confusion. We spoke with the admitting physician on call, who determined that if the patient had a neurologic problem, he was uncomfortable caring for her without neurologic consultation. Unfortunately, there was no neurologist available on call, so we would need to find someplace else for her to go. We found a referral facility willing to accept the patient, but could only gain her acceptance if she needed admission to the ICU. So half the battle won.

Normally she’d take the hop down the interstate to the next big city by ground. However, of the four ambulances in the county, two were broken and the other two needed to be kept in the service area. So the only way to get the patient to the referral center was by plane. It took time for the plane to arrive, for the patient to taken from the ED to the airport, to be flown to the referral center, and to be unloaded at the airport and taken to the hospital. And of course, by the time she arrived at her final destination, she was already starting to wake up, and everyone looked kind of silly.

I tell this story not to blame anyone. Taken in isolation, each piece of the story makes perfect sense. The patient should not be subject to 12 hours in the ED, and admission was clearly warranted. You shouldn’t force any physician to care for a patient when they’re uncomfortable with that level of care, so the patient needed to be transferred someplace. You can’t take needed EMS units out of a community, so other transport resources need to be utilized. And things take time, and time changes things. Two wrongs don’t make a right, but in this case multiple rights surely added up to a wrong. But that’s health care in America.

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It was a good night. Never too busy, patients pretty straightforward. Got to sleep in the wee small hours and didn’t wake up ‘til sunrise. And it’s the kind of shift you dread when you leave at 7 AM, because you know that the Law of Averages means you’ll pay for it tomorrow.

Wednesday, March 2, 2011

There was a Medical Staff Meeting the other day, but I didn’t attend. ED docs don’t often go to Medical Staff Meetings. Except for the Medical Director of the Department, we’re often not as invested in medical staff issues. We come to work, get paid by the hour, and go home. And given that medical staff meetings occur at hours when we’re either still at work, getting ready to come to work, sleeping off the prior shift, or keeping our private time private (one reason why many of us went into ER…no office, no call, no pager), it’s not all that surprising. (My own rationale for missing the meeting was to grab every wink of sleep until the last possible moment before my twelve hour twilight journey.)

That being said, I was able to sneak down towards the meeting room and steal a plateful of shrimp cocktail before heading up to the ED to start work. I put the plate in the break room, figuring that anyone who wanted could share in the feast. Which led to the following conversation, overheard between two nurses:

“You know, those look really good. I really want to eat one even though I shouldn’t.”

“I don’t know. l really don’t like them very much at all. They always seem so flaccid and small, and taste so fishy.”